Frequency of dyslipidemia in normotersive non diabetic obese patients

Objective: to determine the frequency of dyslipidemia in normotensive, non-diabetic obese patients

Methods: it was a cross sectional study including admitted patients and patients visiting outdoor. After obtaining informed consent, demographic information such as name, age, gender was collected .This study included 200 normotensive, non-diabetic obese patients. Serum lipid profile was checked in all patients. The frequency and pattern of dyslipidemia was assessed which was described in frequency distribution tables

Results: the mean total Cholesterol, mean LDL C, HDL and Triglyceride levels were 211.59 +/- 42.39 mg/dl, 131. 39 +/-17.21 mg/dl, 36.46+/-7.93 mg/dl and 164.69 +/- 11.80 mg/dl, respectively. The dyslipidemias were found in 87 [43.5%] patients

Conclusion: the frequency of dyslipidemias is high among normotensive non diabetic obese patients. So, every patient with obesity should be screened with lipid profile

Efficacy of rifaximin in treatment of hepatic encephalopathy

Objective: to compare the efficacy of rifaximin vs control group in addition to lactulose for treatment of hepatic encephalopathy with constipate

Methods: a total 100 patients were enrolled in this study. After taking an informed consent the demographic data was collected. Patients were well informed regarding the treatment and its possible effect. The patients were examined for the confirmation of hepatic encephalopathy with constipation. Patients were randomly divided into two groups. Group A received additional rifaximin with lactulose and Group B received only lactulose. The treatment was continued for four months and then patients were observed

Results: in our study, 18% [n=9] in Group-A and 24% [n=12] in Group-B were between 18-30 years of age while 82% [n=41] in Group-A and 76% [n=38] in Group-B were between 31-60 years of age, mean+/-sd was calculated as 47.7+/-10.44 and 46.1 +/-10.77 years respectively. Comparison of efficacy in both groups shows 68% [n=34] in Group-A and 58% [n=29] in Group-B while 32% [n=16] in Group-A and 42% [n=21] in Group-B had no findings of efficacy

Conclusion: we concluded that the efficacy of rifaximin is significantly better when compared to control group in addition to lactulose for treatment of hepatic encephalopathy with constipation

Prediction of oesophageal varices in cirrhotic patients by prothrombin time as a non-invasive marker

Objective: the objective of the study was to determine the diagnostic accuracy of prothrombin time for the non-invasive diagnosis of esophageal varices keeping upper gastrointestinal endoscopy as Gold Standard

Methods: the study was conducted in Medical unit 4, Services Hospital Lahore over a period of 6 months. It is a cross-sectional study

Results: in our study, 43.5%[n=87] were between 12-30 years and 56.5%[n=113] were between 31-60 years, mean+/-sd was calculated as 39.90+/-12.29 years, 43.5%[n=87] were male and 56.5%[n=113] were females, frequency of esophageal varices keeping upper gastrointestinal endoscopy as gold standard was recorded in 57%[n=114] while 43%[n=86] had no findings of the morbidity, diagnostic accuracy of prothrombin time for the non-invasive diagnosis of esophageal varices keeping upper gastrointestinal endoscopy as gold standard 53%[n=106] true positive, 2%[n=4] false positive, 4%[n=8] false negative and 41 %[n=82] as true negative. Whereas specificity, sensitivity, positive predictive value, negative predictive value and diagnostic accuracy was calculated as 92.98%, 95.35%, 96.36%, 91.11 %, and 94% respectively

Conclusion: we concluded that the predictive value of prothrombin time for presence of oesophageeal varices is a higher and it is a useful non-invasive diagnostic modality

Frequency of thyroid dysfunction in patients of chronic hepatitis C treated with interferon alpha 2B and ribavirin

Objective: to determine the frequency of thyroid dysfunction in patients of chronic hepatitis C treated with Interferon alpha 2b and Ribavirin

Methods: a total of 120 cases having active hepatitis C assessed by HCV RNA PCR as per operational definition for at least 3 months between 15 years to 60 years of both gender were included in the study from outdoor of Services Hospital Lahore after a written informed consent. All the demographics including name, age, gender and address were entered in a pre-defined questionnaire. Patients were treated with Interferon alpha 2b [dose] three million international units subcutaneously three times a week and Ribavirin [dose] 1200 mg oral dailyfor24 weeks. As per hospital routine Thyroid dysfunction was evaluated as per operational definitions bycollecting4ml of blood in a 5cc syringe at 0 [baseline] and 12 week. Presence or absence of thyroid dysfunction at 12 weeks was labelled as per operational definition

Results: in our study, out of 120 cases, 42.5% [n=51] were between 15-40 years while 57.5% [n=69] were between 41-60 years of age, mean +/-sd was calculated as 42.49+/-11.54 years, 59.17% [n=71] were male while 40.83% [n=49] were females, frequency of thyroid dysfunction in patients of chronic hepatitis C treated with interferon alpha 2b and ribavirin was recorded in 21.67% [n=26]

Conclusion: we concluded that the frequency of thyroid dysfunction in patients of chronic hepatitis C treated with Interferon alpha 2b and Ribavirin is not very high but reaches at a considerable level and necessary steps should be taken for the management of this morbidity while interferon therapy is given to the Hepatitis C virus cases

Xantho granulomatous pyelonephritis presenting as migratory polyarthritis in 40 years old female in department of medicine in services hospital Lahore

We report a case of Xantho granulomatous pyelonephritis presenting with migratory polyarthritis in a 40 years old female patient. The patient presented to us with complaint of high grade fever and large joints pain and swelling. The diagnosis was confirmed with CT-scan abdomen and histopathology of specimen. Xantho granulomatous pyelonephritis is an unusual variant of chronic pyelonephritis. Fleeting arthritis is very rare presenting complaint of the disease

Postural hypotension in male diabetics with autonomic cardiovascular dysfunction and impotence

Objective: to find out frequency of postural hypotension in male diabetics with autonomic cardiovascular dysfunction and impotence

Material and Methods: a total of 200 male diabetic patients, attending Diabetes Management Centre Services Hospital Lahore, were enrolled in the study. All the diabetic patients between ages 14-60 years, having fasting blood sugar level more than 126 mg/di, were included. A detailed history was taken and all patients underwent relevant physical examination; blood pressure was taken in supine and standing position and investigations like random blood sugar levels were checked. The diagnosis of autonomic cardiovascular dysfunction was documented by heart rate response to Valsalva maneuver. The ratio of longest R-R to shortest R-R is< 1.2 during Valsalva in patients with autonomic cardiovascular dysfunction. The postural hypotension in diabetic patients was calculated after recording the postural drop in all the patients. Before assessing blood pressure variation with postural change, 20 min supine rest was mandatory

Results: the age range was from 14-60 years. The percentage of patients with postural drop was 32 percent in the presence of parasympathetic dysfunction. The mean age of patients with parasympathetic dysfunction was 50.65+/-5.53 years

Conclusion: postural hypotension does not seem to be a good marker for autonomic neuropathy. The proportion of patients having postural hypotension in the presence of parasympathetic dysfunction was not significant in the study population. However significant correlation of postural hypotension with duration of diabetes was found

Prevalence of congestive gastro and doudenopathy in patients with portal hypertension

The aim of this study was to determine the prevalence of congestive gastropathy/ duodenopathy in portal hypertension. A cross sectional study of 100 patients with portal hypertension undergoing upper gastro-intestinal endoscopy in Medical Unit IV was carried out in which their history, clinical and endoscopic examination was done. Congestive gastropathy was seen in 88% of the patients, while congestive duodenopathy was seen in 19% of the patients. The study data analysis leads to the conclusion that the congestive gastropathy can by included as one of the common complications of advanced liver cirrhosis

Association of progression of pulmonary fibrosis with severity of liver cirrhosis

Background: it has been found that frequency of pulmonary fibrosis increases in patients with cirrhosis of liver. We hypothesized that as the stage of cirrhosis advances, the frequency of pulmonary fibrosis should increase. We used child's pugh classification to stage the cirrhosis of liver

Material and Methods: fifty five patients of age range 16 to 80 years, both males and females having established cirrhosis of Fiver on ultrasonography, regardless of etiology, visiting the outpatient and inpatient department for treatment were selected. Patients were divided into three groups according to child's criteria i.e. group A, group B, and group C. HRCT of chest was performed on patients in all three groups to look for pulmonary fibrosis

Results: 27 [49%] patients were found to have pulmonary fibrosis on HRCT. The frequency of pulmonary fibrosis in different groups of child's classification was also assessed and it was found that class C and class B, are affected more than A

Conclusion: pulmonary fibrosis progresses with severity of liver cirrhosis

Comparison of efficacy of topical glycerin trinitrates with capsaicin in painful diabetic neuropathy

Objective: to compare the efficacy of topical glycerin triturates with capsaicin in painful diabetic peripheral neuropathy

Material and Methods: this quasi experimental study was conducted in Diabetes Management Centre Medical Unit-IV Services Hospital, Lahore over a period of six months from 01-06-2008 to 30-11-2008. Sixty-two patients of diabetes mellitus having symptoms of neuropathy were included in this study and were divided into two groups of thirty one patients each: .In group A topical capsaicin cream was applied twice a day for thirty minutes for the period of seven days aft he strength of 0.075% w/w. In group B glycerin triturate cream was applied twice a day for thirty minutes for the period of seven days at the strength of 2% w/w. After seven .days of treatment, intensity of numbness and par aesthesia and tissue perfusion were again assessed using visual analogue scale and Perl scan respectively. Perl scan and visual analogue chart assessment were repeated after the seven days wash out period and patients were .crossed over to the other treatment group. Numbness and para aesthesia were reassessed at the end of last treatment on visual analogue chart and Perl scan were repeated as well for tissue perfusion

Results: the age of the patients in group .A. was49:90+/-8.06 years and in group B were 49.58+/-6.62 years. In group A, the efficacy of GTN in peripheral neuropathy was 38.7% as compared to capsaicin which was only 19.3%. Similar results were seen in group B, in which efficacy of GTN in peripheral neuropathy was 51.6% as compared to capsaicin that was 29%.The overall results when combined in both the groups showed a response to capsaicin in 15 [24.2%] patients only versus 28 [45.2%] to GTN. This difference was statistically significant [p=0.02356]

Conclusion: there is a significant difference in efficacy of topical glycerin triturates and capsaicin in the management of diabetic peripheral neuropathy. GTN cream, a well-tolerated drug, provides significant improvement in painful diabetic neuropathy

Non invasive assessment of liver fibrosis in chronic liver disease

Background: Chronic hepatitis C [CMC] infection leads to necroinflammation which causes fibrosis and ultimately cirrhosis in 20% of cases. Liver biopsy is recommended for assessment of hepatic fibrosis and is thought to be the gold standard. Recurrent bouts of hepatocellular necrosis in CMC infection cause episodic rise in aminotransferases especially alanine aminotransferase [ALT]. ALT levels decrease as fibrosis advances and AST levels tend to exceed ALT. This results in increase in AST/ALT ratio >1.0, which can be used as non-invasive marker of hepatic fibrosis and cirrhosis, thus reducing the number of liver biopsies performed in patients with AST/ALT ratio >1.0

Objectives: To assess the accuracy of serum aminotransferases [AST/ALT] ratio for determining the severity of hepatic fibrosis in patients with chronic hepatitis C, considering histopathological findings as gold standard

Study Design: Cross sectional survey

Setting: Medical unit 4, Services Institute of Medical Sciences [SIMS]/ Services Hospital, Lahore

Duration: The study was completed over a period of 6 months; from 15th October, 2008 to 15th April, 2009

Subject and Methods: Seventy HCV positive with detectable RNA by Polymerase Chain Reaction, fulfilling the criteria were selected. AST and ALT levels were measured in [IU/L]. Upper limit of both AST and ALT was taken as 40 IU/L. AST/ALT ratio was calculated as under; AAR = AST [IU/L], ALT [IU/L] All these patients also underwent percutaneous liver biopsies and then histopathologist staged biopsy for fibrosis according to Ishak/Knodell criteria

Results: AST/ALT ratio of more than 1.0 was associated with severe fibrosis/ cirrhosis [F4- f6]

Conclusion: Study showed that AAR more than 1.0 has significant association with severe fibrosis and identifies CMC patients with marked fibrosis/ cirrhosis, and its application can decrease the need for performing liver biopsies for staging

Frequency of rectal varices in cirrhotic patients

Background: Most cirrhotic patients develop esophageal varices, with a lifetime incidence as high as 80-90%. Approximately 20% - 30% of cirrhotic patients with esophageal varices develop an episode of esophageal hemorrhage, which has a high mortality of nearly 20 30% with each episode of bleeding

Objectives: To determine the frequency of rectal varices in cirrhotic patients with esophageal varices

Study Design: Cross-sectional survey

Setting: Study was carried out in the Department of Medicine, Unit-4, Services Hospital, Lahore

Duration of Study With Dates: Study was carried out over a period of six months from 18-02- 2009 to 17-08-2009

Subjects and Methods: Total 150 patients were recruited in this study fulfilling the inclusion criteria. Per-rectal proctoscopy was performed in those patients who had esophageal varices and presence or absence of rectal varices documented

Results: Mean age of the patients was 45.5±8.6. 119 [79.3%] were male and 31 [20.7%] were females. Rectal varices were present in 70 patients [46.7%]. Out of total of 31 female patients included, rectal varices were present in 13 patients [41.9%] and were absent in the remaining 18 patients [58.1%]. As far as the male patients are concerned, out of the total 119 patients, rectal varices were present in 57 patients [47.8%] and absent in the remaining 62 patients [52.2%]

Conclusion: Rectal varices are common in patients with portal hypertension. In patients with portal hypertension, and lower Gl bleeding, the possibility of rectal varices should be considered

Assessment of severity of esophageal varices by splenic index in cirrhotic patients

Objective: to determine the relationship between the splenic index and the severity of esophageal varices in cirrhotic patients

Material and Methods: fifty patients who had coarse echotexture of liver on abdominal ultrasound and clinically .palpable spleen were selected. Splenic index was calculated using abdominal ultrasound as a product of longitudinal length and transverse width across the hilus of the spleen. These patients were then subjected to upper gastrointestinal endoscopy and esophageal varices were noticed and severity was assessed using grades from 0-3

Results: relationship was observed between the splenic index and the severity of esophageal Varices

Conclusion: splenic index can be a useful noninvasive method to determine the severity of esophageal varices in patients suffering from hepatic cirrhosis

Frequency of pulmonary fibrosis in patients with cirrhosis of liver

Background: Cirrhosis of liver and pulmonary fibrosis both are chronic inflammatory disorders. Mediators of chronic inflammation include both cytokines and interleukins. The mediators produced during process of fibrosis in liver reach pulmonary circulation which comes first during the pathway; so these mediators should lead to fibrosis in lungs as well

Material and Methods: 55 patients of age range 16 to 80 year, both males and females having established cirrhosis of liver on ultrasonography, regardless of etiology, visiting the outpatient and inpatient departments for treatment of liver disease were selected. High Resolution Computerized Tomography [HRCT] Scan of chest was performed on each patient to look for pulmonary fibrosis

Results: Out of 55 patients 27 [49%]were found to have pulmonary fibrosis on HRCT

Conclusion: Cirrhosis of liver is associated with pulmonary fibrosis in up to 50% of the patients

Use of serum aspartate aminotransferase levels and platelet count to predict hepatic fibrosis in chronic hepatitis C

Background: Chronic hepatitis C [CHC] induces inflammation, resulting in fibrosis. Liver biopsy is the gold standard for assessing histology. Progressive fibrosis results in portal hypertension, splenomegaly, thrombocytopenia and decreased clearance with rise of the enzyme serum aspartate aminotransferase [AST] levels. To amplify this difference in AST and platelet counts in fibrosis, AST-platelet-ratio-index [APRI] was devised using noninvasive serum markers, suggesting that its application may decrease the need for liver biopsy

Material and Methods: Cross sectional descriptive study done in sixty patients of HCV positive state fulfilling the criteria were selected. AST levels [IU/L] expressed as a ratio of upper limit of normal [ULN] taken as 40, were divided by platelet counts[x10[9]/L] and multiplied by 100 to calculate APRI = AST/40 / Platelet count x100 Liver biopsies were then staged by histopathologist for fibrosis according to Ishhaq/revised Knodell criteria

Results: APRI of less than 1.5 was associated with absent or minimal fibrosis F0-F2],whereas values greater than these showed marked fibrosis/ cirrhosis [F3-F6], [p.0001]

Conclusion: Study showed that APRI has significant association with fibrosis and identifies CHC patients with minimal as well as marked fibrosis, and its application may decrease the need for performing liver biopsies for staging

Role of salt intake in the management of cirrhotic Ascites

Background: The purpose of study was to determine the role of salt intake in the management of ascites. Ascites is the most common complication of cirrhosis. Dilutional hyponatremia is present in most of patients with ascites. It is due to excess in antidiuretic hormone which occurs due to decrease in effective arterial volume. Water free salt intake tends to maintain the circulatory volume by drawing the fluid from third space, hence inhibiting ADH. It also increases the response of diuretics by increasing the filtered load of sodium. On the other hand, strict salt restriction and diuretics worsen the hyponatremia and make ascites refractory to treatment

Objective: To determine the role of salt intake in the management of ascites in cirrhotic patients

Methods: It was an interventional experimental study. This study was conducted in Services Hospital, Lahore. Sixty cirrhotic patients with ascites were randomized into two groups to undergo treatment with diuretics and salt restriction during the day. One group [A] was advised salt intake at night with over night fluid restriction, and the other group observed 24 hour salt restriction. The comparison was done in respect to average reduction in weight and abdominal girth over 9 days

Results: The average reduction in weight [p=0.011] and abdominal girth [p=0.003] was significantly more in patients taking salt at night. Moreover these patients also maintained their serum sodium levels [p=0.00001] and majority of them did not need increase in the dose of diuretics or therapeutic ascitic tap

Conclusion: Correction of dilutional hyponatremia by water free salt intake to improve the response of diuretics, gives a safe and effective option for the management of ascites

Use of serum aspartate aminotransferase levels and platelet count to predict hepatic fibrosis in chronic hepatitis C

Background: Chronic hepatitis C [CHC] induces inflammation resulting in fibrosis. Liver biopsy is the gold standard for assessing histology. Progressive fibrosis results in portal hypertension, splenomegaly, thrombocytopenia and decreased clearance with rise of the enzyme serum aspartate aminotransferase [AST] levels. To amplify this difference in AST and platelet count in fibrosis, AST-platelet-ratio-index [APRI] was devised using noninvasive serum markers, suggesting that its application may decrease the need for liver biopsy

Patients and Methods: Cross sectional descriptive study done insixty HCV positive patients fulfilling the criteria. AST levels [IU/L] expressed as a ratio of upper limit of normal [ULN] taken as 9 40, were divided by platelet count [x10 /L] and multiplied by 100 to calculate APRI = [[AST/40]/Platelet Count] x 100. Liver biopsies were then staged by histopathologist for fibrosis according to Ishaq /revised Knodell criteria

Results: APRI of less than 1.5 was associated with absent or minimal fibrosis [F0-F2], whereas values greater than these showed marked fibrosis/ cirrhosis [F3-F6] [p=0.0001]

Conclusion: Study showed that APRI has significant association with fibrosis and identifies CHC patients with minimal as well as marked fibrosis and its application may decrease the need for performing liver biopsies for staging

Relationship between total cystic area of ovaries and acanthosis nigricans in polycystic ovarian syndrome

To correlate the total area of Acanthosis Nigricans with total cystic area of ovaries in women with polycystic ovaries. Thirty young females with polycystic ovaries were selected and in them total cystic area and total area of Acanthosis Nigricans was measured. Mean total cystic area was 92.0 [SD 35.12] and mean total area of Acanthosis Nigricans was 224.46 [SD 234.90]. The relationship between total cystic area [TCA] and total area of Acanthosis Nigricans [TAAN] was statistically significant with p of 0.007. There is a significant correlation between total cystic area and total area of Acanthosis Nigricans in subjects with PCOS. So Acanthosis Nigricans could be a useful cutaneous marker for PCOS and the extensiveness of the cysts presents

Role of clinical diagnosis to ascertain the type of stroke

Background: Cerebrovascular Accident or stroke is a major cause of morbidity and mortality all over the world, including Pakistan. Determination of type of stroke either hemorrhagic or infarct is important for start of any treatment. This study was carried out to compare clinical diagnosis of stroke with Computed tomography [CT] scan findings in ascertaining the type of stroke [hemorrhagicor infarct]

Methods: This study was carried out at Medical unit 3, Services Hospital, Lahore from July 2003 to December 2003 and December 2004 to April 2005. Sixty patients admitted to our ward for stroke lasting more than 24 hours, with at least unilateral motor weakness affecting face and/or arm and/or leg were included in the study. Clinical diagnoses of type of stroke i.e. hemorrhage or Infarct was made using a clinical parameter, with specific emphasis on speed of onset, presence or absence of vomiting, headache and altered state of consciousness. CT scan brain was used as a gold standard in all patients to confirm the diagnosis. The results were compared on case to case basis with CT diagnosis

Results: The study included 60 patients, 44 with ischemic stroke and 16 with hemorrhagic CVA Out of these 60 patients; clinical diagnosis correlated with CT findings in 46 patients [76.66%] whereas in 14 patients [23.33%], CT findings contradicted our clinical suspicion. Clinical accuracy was 84% [37/44] in case of ischemic stroke and 56% [9/16] in hemorrhagic stroke

Conclusion: The study has shown that although clinical evaluation of acute stroke can be made in most cases but CT scan is mandatory for excluding hemorrhage before start of treatment

Helicobacter pylori-role in decompensation of patient with HCV positive chronic liver disease

Background: H. Pylori is prevalent in the developing world and is implicated in the pathogenesis of acid peptic disease and liver disorders. As patient with CLD may present with symptoms of acid peptic disease, a study was conducted to see if there is any correlation between H. Pylori and liver disorders

Methods: It was a prospective cross-sectional study of 60 patients, anti-HCV positive, who presented to Medical Unit-lll of Services Hospital, Lahore from March to August 2005. They were divided into groups as patients with compensated and de-compensated liver disease. All of them were tested for H. Pylon antibodies by Immunoassay

Results: Five patients [16.6%] of the compensated group were H. Pylori positive whereas 16 patents [53.3%] in the decompensated group were positive

Conclusion: There is a possible association between Helicobacter Pylori and progression of chronic Ever disease